Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Comorbid Conditions

Factors Influencing Duration

Factors include occupation, age, and conditioning of the individual. Compliance with treatment and recommended home care will influence the duration. Any conditions affecting the spine could prolong recovery. The individual's need and ability to obtain secondary gains from the pain could lengthen disability time. Psychological assessment is crucial in cases with prolonged disability and no obvious specific spinal disorder.

Medical Codes

ICD-9-CM:

724.2 -

Lumbago; Low Back Pain; Low Back Syndrome; Lumbalgia

Overview

Low back pain is a symptom, not a specific disease. Low back pain is usually described as discomfort in the lumbosacral region of the back that may or may not radiate to the legs, hips, and buttocks. The pain may be due to a variety of causes, and many individuals may never receive a clear diagnosis for the cause of the pain. A small percentage may have a serious disease unrelated to the back.

Although low back pain may be caused by medical conditions such as infection or cancer, the vast majority of low back pain cases are attributed to mechanical or musculoskeletal conditions. These conditions include lumbosacral muscle and ligament strains and sprains; disorders of the intervertebral discs and associated joints such as degeneration (spondylosis); degeneration that narrows the space through which spinal nerves pass (spinal stenosis); disc displacement (herniation of a disc); disorders of the vertebral body, such as slippage (spondylolisthesis) or fracture; or structural deformities, such as scoliosis. This section will focus on mechanical and musculoskeletal conditions that cause low back pain.

Low back pain ranks second only to upper respiratory infections as a cause of lost work productivity. It accounts for approximately 175.8 million days of restricted activity annually in the US (Patel).

Incidence and Prevalence: In the US, the incidence of lower back pain over the course of a person’s life is approximately 60% to 90%; the annual incidence for the population as a whole is 5%. The National Center for Health Statistics reports that this accounts for 13 million visits to the doctor each year. With 2.4 million people excused from work during any period, low back pain is a major factor in lost productivity (Patel).

Causation and Known Risk Factors

An initial episode of back pain typically occurs between 30 and 40 years of age. The likelihood of having low back pain increases with age. However, the condition has become increasingly prevalent in pre-teens and teens, and has been attributed to weighty backpacks and incorrect posture while using video games and computers. Overall deconditioning is also likely to contribute to low back pain. Added stress to the back from any cause such as obesity, pregnancy, or unnatural curvature or disease of the spine can increase the risk for back pain. Occupational risk factors include lifting objects while twisting or without properly bending the legs, heavy pushing or pulling, and vibrational stresses. A family history may predispose individuals to some causes of back pain, such as degenerative disc disease.

Diagnosis

History: Individuals may complain of stiffness, local tenderness, generalized discomfort, and weakness of the lower back. Pain that radiates to the posterior thigh may reflect referred pain from myofascial, sacroiliac, or facet joint involvement. Pain that radiates to the leg, in the distribution of a nerve root (radiculopathy), may indicate nerve involvement. Pain that gets little relief from rest may suggest compression fracture or malignancy. Dramatic symptoms of neural compromise may imply uncommon conditions such as an epidural abscess or cauda equina tumor. More often, low back pain is aggravated by activity and improved by rest. Certain types of back pain do not originate in the back at all but from other tissues or organs. This is called referred pain, and the individual's history may provide information about the affected structure.

Most episodes of low back pain have no apparent cause. It is, however, important to rule out those causes of low back pain that require more urgent attention, including fracture, infection, tumor, or systemic conditions. The history may focus on when and under what circumstances the pain began. Information may be gathered regarding a possible precipitating incident such as a fall or an episode of heavy lifting. Questions may be asked regarding the pain: Has it worsened or improved? Are there any activities that aggravate or diminish it? Is it intermittent? Is it worse at a particular time of the day? Has the quality of the pain changed?

Perhaps one of the most important questions is whether this is the first episode of this particular type of pain. Recurrent low back pain is very common, and back pain is an episodic condition. With over 80% of adults having experienced low back pain, a complaint that this episode of pain is different from prior episodes or more persistent may be cause for more extensive testing.

Physical exam: Individuals are examined in three positions: lying flat (supine), sitting, and standing. The exam includes visual inspection for obvious asymmetry, deformities, or accentuated spinal curves. Posture, gait, and range of motion are evaluated. Neurological examination assesses reflexes, muscle strength, sensation, and gait. Palpation along the spine, muscles, and tendon insertions can reveal areas of localized tenderness. Examination of the circulation in the lower extremities is important to exclude vascular causes of leg pain.

Tests: In many cases, testing is not needed for simple low back pain. When testing is required, the type and amount are determined by the severity of the pain, whether it is chronic, and the individual's history of trauma or signs or symptoms (frequently called "red flags") suggesting the possibility of serious disease like spinal infection or tumor. In order to be considered diagnostic, test results must closely correlate with symptoms.

Plain x-rays reveal most fractures and deformities (e.g., scoliosis, spondylolisthesis) and may reveal more advanced spinal infections or tumors. Aside from these conditions, the age-related changes and/or anomalies visible on x-ray are not specific and do not generally correlate with the individual's symptoms.

Bone scans, MRI, and CT scans are used to rule out infection or tumor, if musculoskeletal pain is not the obvious diagnosis. In general, in the absence of specific symptoms or signs to suggest fracture, infection, or tumor, no imaging studies or tests are indicated initially. If tumor or infection is suspected, blood (complete blood count and erythrocyte sedimentation rate) and urine tests will generally be performed. Neurological testing may include electromyography (EMG) and nerve conduction studies if radiculopathy is suspected.

Provocative tests, such as discography or analgesic injections, are extremely controversial tests believed by proponents to help identify whether a specific disc or nerve root is the source of pain. These tests are not usually performed until the individual has failed a course of nonoperative care. Discography is usually performed in anticipation of surgery; nerve root injections may be both diagnostic and therapeutic.

Treatment

Pain without an underlying diagnosis is treated conservatively with tolerable activity and reassurance. Simple analgesics and nonsteroidal anti-inflammatory drugs (NSAID) may be appropriate. Muscle relaxants are frequently prescribed, but their effectiveness comes from their sedative action. Use of light support corsets is sometimes suggested to help with the pain, but their value has come under question. For acute back pain, it has been found that the resumption of activity as tolerated is superior to bed rest (activity facilitates recovery), but short periods of bed rest may be necessary for severe symptoms. In cases of chronic pain that is unresponsive to conservative treatment, some doctors may choose to administer steroids and other injections in an effort to decrease pain and inflammation. Types of injections and the likelihood of their use vary among physicians (“Back Pain”).

Spinal manipulation may decrease the pain, especially in the first 4 to 6 weeks after the onset of pain.

In the vast majority of cases, surgery is not needed for simple low back pain. Underlying conditions and diseases that may necessitate surgery include herniated discs, spinal stenosis, vertebral fractures, and degenerative disc disease.

* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Prognosis

Individuals suffering from uncomplicated back pain usually recover from the acute episode, though recurrence is common. Forty to fifty percent of individuals are symptom-free within 1 week of onset of pain. Up to 90% of simple back pain symptoms resolve without medical attention in 6 to 12 weeks (Patel).

Rehabilitation

The goal of rehabilitation for low back pain is to decrease pain and to promote an active lifestyle and regular participation in an exercise program, helping the individual regain mobility and strength to that particular region of the spine (Malmivaara).

Therapy to reduce symptoms followed by spinal exercises may be all that is required for mild cases. However, more involved rehabilitation is required for severe symptoms. Passive intervention should be time limited, with emphasis on active exercise. Rehabilitation will be based upon the duration of time from the onset of symptoms.

Acute Phase (up to 7 days): Recovery may be improved by a few sessions of manipulation, followed by instruction on comfortable postures and positions that are safe for the spinal structures. The individual should be encouraged to resume activities that can be tolerated (Bigos).

Sub Acute Phase (2 to 12 weeks): Instruction should be given on an exercise program that will help maintain the individual's well being. Physical therapy will include modalities such as moist heat and electrical stimulation to control pain in order to promote physical activity. The individual may also benefit from spinal injections for pain control. During this phase, the work place should undergo an ergonomic evaluation so that changes may be implemented to help the employee return to work. Toward the later stages of this phase, if the individual shows a lack of or slow progress, a psychologist should evaluate the individual to determine whether or not there are signs of psychological distress secondary to the injury (Kendall). There is evidence that a multidisciplinary treatment approach can be effective in treating these individuals and returning them to a full level of activity (Loisel).

Chronic Phase (more than 12 weeks): Exercise instruction must continue, the program combining coordination, aerobic conditioning, and flexibility. The individual should continue to be educated on functional exercises and proper body mechanics. A short course on cognitive pain management may be beneficial. If not already performed, an ergonomic evaluation with modifications may enable the individual to maintain or return to work and reduce the risk of re-injury. Vocational services should be available for individuals who cannot return to their previous job title or do not have a job to which to return (van Tulder).

FREQUENCY OF REHABILITATION VISITS

Nonsurgical

Specialist

Low Back Pain

Physical Therapist

Up to 12 visits within 6 weeks

Physical Therapist

Daily up to 6 weeks †

Occupational Therapist

Daily up to 6 weeks †

Chiropractor

Up to 3 visits within first week of onset

Clinical Psychologist

Up to 2 visits within 6 weeks of onset

Clinical Psychologist

Up to 12 visits within 6 weeks †

Ergonomist

Up to 2 visits within 8 weeks

Vocational Counselor

Up to 3 visits within 6 weeks †

† As part of multidisciplinary intervention (work condition).

The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Complications

Low back pain due to simple muscle or ligament sprain or strain does not result in real medical complications. Lower back problems that involve the vertebral discs carry the risk of nerve root impingement.

Ability to Work (Return to Work Considerations)

Heavy or unassisted lifting; repetitive rotation of the back; carrying, pushing, or pulling heavy objects; vibrational stresses; overhead work; and prolonged sitting are to be avoided early on. Prolonged standing should be evaluated for aggravation of the pain. Rest periods are an important part of both treatment and prevention. Some health care providers may recommend wearing a lumbosacral support. Use of medications such as pain relievers (analgesics) and muscle relaxants will necessitate review of safety issues and drug-testing policies. Recurrence of back pain is common, and education regarding safer work practices for lifting, carrying, pushing, pulling, and sitting can help decrease or prevent recurrence.

Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

Is this individual's first episode of pain, or is it recurrent?

Have infection and cancer been ruled out in the individual?

Was adequate testing done for individual to establish the diagnosis?

Has an MRI been obtained?

Have conditions with similar symptoms been ruled out?

Does individual's pain radiate to either leg?

Did individual experience a recent fall or stumble?

Has a second opinion been obtained from an appropriate specialist?

Regarding treatment:

Is individual active in physical therapy?

How did individual respond to conservative treatment?

Was it necessary for individual to have surgery?

Regarding prognosis:

Is individual actively participating in physical therapy and a home exercise program?

Has work conditioning been implemented? Was pain behavior noted during work conditioning?

Has a work site visit occurred to negotiate a modified-duty return-to-work compromise?

Has a functional capacity assessment been done to have a general idea of activity tolerances?

Is individual involved in any hobbies or other activities that can strain the back? If overweight, is individual enrolled and participating in a weight loss program?

Is individual experiencing secondary gains from low back pain?

Is individual experiencing stressful situations that may be intensifying his or her pain? Has a psychological assessment been obtained?

Chou, Roger, et al. "Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society." Annals of Internal Medicine 147 7 (2007): 478-491.

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